<link href="//maxcdn.bootstrapcdn.com/bootstrap/3.3.0/css/bootstrap.min.css" rel="stylesheet" id="bootstrap-css"> <script src="//maxcdn.bootstrapcdn.com/bootstrap/3.3.0/js/bootstrap.min.js"></script> <script src="//code.jquery.com/jquery-1.11.1.min.js"></script> <!------ Include the above in your HEAD tag ----------> <div class="container"> <div class="row"> <div class="col-md-6"> <div class="well-block"> <div class="well-title"> <h2>Questions? Book an Appointment</h2> </div> <form> <!-- Form start --> <div class="row"> <div class="col-md-6"> <div class="form-group"> <label class="control-label" for="name">Name</label> <input id="name" name="name" type="text" placeholder="Name" class="form-control input-md"> </div> </div> <!-- Text input--> <div class="col-md-6"> <div class="form-group"> <label class="control-label" for="email">Email</label> <input id="email" name="email" type="text" placeholder="E-Mail" class="form-control input-md"> </div> </div> <!-- Text input--> <div class="col-md-6"> <div class="form-group"> <label class="control-label" for="date">Preferred Date</label> <input id="date" name="date" type="text" placeholder="Preferred Date" class="form-control input-md"> </div> </div> <!-- Select Basic --> <div class="col-md-6"> <div class="form-group"> <label class="control-label" for="time">Preferred Time</label> <select id="time" name="time" class="form-control"> <option value="8:00 to 9:00">8:00 to 9:00</option> <option value="9:00 to 10:00">9:00 to 10:00</option> <option value="10:00 to 1:00">10:00 to 1:00</option> </select> </div> </div> <!-- Select Basic --> <div class="col-md-12"> <div class="form-group"> <label class="control-label" for="appointmentfor">Appointment For</label> <select id="appointmentfor" name="appointmentfor" class="form-control"> <option value="Service#1">Service#1</option> <option value="Service#2">Service#2</option> <option value="Service#3">Service#3</option> <option value="Service#4">Service#4</option> </select> </div> </div> <!-- Button --> <div class="col-md-12"> <div class="form-group"> <button id="singlebutton" name="singlebutton" class="btn btn-default">Make An Appointment</button> </div> </div> </div> </form> <!-- form end --> </div> </div> <div class="col-md-6"> <div class="well-block"> <div class="well-title"> <h2>Why Appointment with Us</h2> </div> <div class="feature-block"> <div class="feature feature-blurb-text"> <h4 class="feature-title">24/7 Hours Available</h4> <div class="feature-content"> <p>Integer nec nisi sed mi hendrerit mattis. Vestibulum mi nunc, ultricies quis vehicula et, iaculis in magnestibulum.</p> </div> </div> <div class="feature feature-blurb-text"> <h4 class="feature-title">Experienced Staff Available</h4> <div class="feature-content"> <p>Aliquam sit amet mi eu libero fermentum bibendum pulvinar a turpis. Vestibulum quis feugiat risus. </p> </div> </div> <div class="feature feature-blurb-text"> <h4 class="feature-title">Low Price & Fees</h4> <div class="feature-content"> <p>Praesent eu sollicitudin nunc. Cras malesuada vel nisi consequat pretium. Integer auctor elementum nulla suscipit in.</p> </div> </div> </div> </div> </div> </div> </div> Created by <a href="http://jituchauhan.com/">Jitu Chauhan</a>

.well-block { background-color: #fff; border: 1px solid #e9e6e8; padding: 40px; } .well-title { margin-bottom: 40px; }